How to Hack Your Brain When You're in Pain | Amy Baxter | TED

Summary

In this insightful talk, the speaker challenges the conventional view of pain as merely a distress signal to be silenced. They argue that pain is a complex learning system for survival, shaped by physiology, fear, and control. The speaker shares their research on innovative pain management techniques, such as the Buzzy device, which uses vibration and cold to reduce pain without opioids. They also emphasize the importance of reframing our approach to pain, moving away from the unrealistic goal of 'pain-free' to a more achievable 'more comfortable,' and highlight the dangers of opioid overuse.

Takeaways

• 🤕 Pain is not just a localized sensation but a complex process involving nerves, the spine, and the brain.
• 🏥 Medical professionals receive minimal education on pain management, often influenced by pharmaceutical marketing.
• 💊 The '90s saw a push for 'pain-free' as a goal, which was heavily marketed by pharmaceutical companies, leading to opioid overprescription.
• 🔁 The speaker's friend's son, Christopher, became addicted to opioids after being prescribed OxyContin for post-surgical pain, highlighting the dangers of opioid misuse.
• 🦾 Pain should be reconceptualized as a learning system for survival, rather than merely an alarm to be silenced.
• 🧠 The speaker proposes a Venn diagram model for understanding pain, involving physiology, fear, and control.
• 🐝 The invention of Buzzy, a device combining vibration and cold to block pain during injections, has been successful in reducing pain and opioid use.
• 🧊 The physiological effects of cold can decrease overall pain sensation by influencing the brain's interpretation of danger.
• 🔢 Distraction techniques, such as counting, can reduce pain by engaging the decision-making part of the brain, thus lessening the perception of pain.
• 🧠 Functional MRI has shown that pain is a complex network of brain connections, involving sensation, decision-making, fear, memory, and control.
• 🌡️ The speaker suggests that personalizing pain management options, such as heat, cold, vibration, and relaxation techniques, can be more effective than a one-size-fits-all approach.
• 💊 Opioids do not turn off a 'pain switch' but rather activate the brain's reward system, which can be risky for some individuals.
• 🛑 The speaker advocates for reducing opioid prescriptions for home recovery and promoting alternative pain management strategies.

Q & A

What is the common misconception about pain that the speaker addresses?

The common misconception is that pain is localized to the area where it is felt, whereas the speaker explains that pain is actually processed in the brain after signals from nerves are translated in the spine.

How much pain education do medical students typically receive according to the speaker?

The speaker mentions that medical students receive only two days of pain education throughout their entire medical school.

What was the impact of pharmaceutical marketing on the speaker's medical education regarding pain management?

The speaker recalls a lecture sponsored by OxyContin, where they were taught that opioids were not addictive and could keep patients pain-free, which was influenced by marketing rather than scientific evidence.

What tragic outcome did the speaker's friend's son, Christopher, experience due to opioid use?

Christopher became addicted to opioids after being prescribed OxyContin for pain management following surgery, eventually turning to heroin and losing his battle with substance use at the age of 32.

What is the speaker's proposition about the nature of pain in relation to survival?

The speaker suggests that pain is not just an alarm to silence but a learning system for survival, teaching organisms to avoid harmful stimuli.

What is the 'gate control' theory mentioned by the speaker in relation to pain?

The 'gate control' theory refers to the physiological mechanism where certain types of nerve signals, such as those from light touch, pressure, and motion, can 'shut the gate' on pain signals, thereby reducing the perception of pain.

Can you explain the concept of a 'pain hack' as introduced by the speaker?

A 'pain hack' is a technique or method to reduce the perception of pain, such as counting letters with holes in a sentence or using physical stimuli like cold and vibration, which can distract the brain and lessen the sensation of pain.

What is the significance of the 'Buzzy' device in the speaker's narrative?

The 'Buzzy' device is a pain management tool that combines vibration and cold to block pain, which the speaker discovered could also help in managing pain from a total knee replacement without the use of opioids.

How does the speaker describe the role of fear and control in the perception of pain?

The speaker describes fear and control as 'volume knobs' for pain, where fear can amplify pain sensations and a sense of control can reduce them, suggesting that managing these aspects can be key in pain management.

What is the speaker's stance on the use of opioids for pain management?

The speaker acknowledges the value of opioids for certain cases, such as chronic pain diseases or trauma, but criticizes their overprescription and the risks of addiction, advocating for alternative pain management strategies.

What is the speaker's vision for the future of pain management in healthcare systems?

The speaker envisions healthcare systems providing paid-for options and coaching for pain management, moving away from the overreliance on opioid prescriptions and towards a more holistic approach that includes various physiologic options and patient education.

Outlines

00:00

🤕 Rethinking Pain Management

The speaker begins by challenging the conventional understanding of pain as a localized sensation, explaining that pain is actually processed in the brain and can be influenced by various factors. They critique the lack of education on pain in medical school and the misleading marketing of opioids, which has contributed to the opioid crisis. The speaker shares a personal story about a friend's son, Christopher, who became addicted to opioids after being prescribed them for pain management. They propose that pain should be viewed as a learning system for survival rather than something to be eliminated, and introduce the concept of a 'pain Venn diagram' involving physiology, fear, and control.

05:01

🔬 The Science of Pain Relief

This paragraph delves into the physiological mechanisms behind pain relief, particularly the use of vibration and cold to block pain signals. The speaker explains the 'gate control' theory, which suggests that certain types of nerve stimulation can 'shut the gate' on pain transmission. They also discuss the role of distraction and decision-making in reducing pain perception, using the example of counting monkeys on a poster. The speaker shares a personal anecdote of using a cold beer and a vibrator to manage pain from a coffee spill during a turbulent flight, emphasizing the effectiveness of combining different pain relief techniques.

10:02

🛡️ Taking Control of Pain

The speaker discusses the importance of understanding and managing pain through a combination of physiological, psychological, and behavioral approaches. They highlight the role of fear and control in pain perception, suggesting that by managing these factors, individuals can reduce their pain experience. The speaker also addresses the misconceptions about opioids, explaining that they do not turn off a pain switch but rather activate the reward system, which can lead to addiction. They advocate for a shift in healthcare practices to provide better pain management options and coaching, and encourage the audience to discard unused opioids and explore alternative pain relief methods.

15:02

🦄 Innovations in Pain Management

In this final paragraph, the speaker introduces their work on a new application for their pain relief device, DuoTherm, which explores the interaction of different frequencies to target pain from the fascia between the skin and muscles. They discuss the potential of this technology to engage various areas of the brain associated with pain, offering a more comprehensive approach to pain management. The speaker concludes by emphasizing the importance of innovation and personal control in reframing and managing pain.

Keywords

💡Pain

Pain is a complex sensory and emotional experience typically associated with actual or potential tissue damage. In the video, pain is redefined as a learning system for survival rather than merely a distress signal. The speaker uses the example of a thumb being hit with a hammer to illustrate how pain is processed by the nervous system and experienced in the brain, emphasizing its role in alerting us to potential harm.

💡Opioids

Opioids are a class of drugs that include opium-derived substances such as morphine and codeine, as well as synthetic drugs like oxycodone. The script discusses the misconception that opioids are non-addictive and can be used to maintain a 'pain-free' state, which has led to widespread addiction and abuse, as exemplified by the tragic story of Christopher Wolf.

💡Gate Control Theory

The Gate Control Theory is a concept in neuroscience that explains how the perception of pain can be modulated by the nervous system. The speaker mentions this theory to explain how the right frequency of vibration can 'shut the gate' on sharp pain, thereby reducing the sensation of pain, which is a key principle in the development of the Buzzy device.

💡Buzzy

Buzzy is a device invented by the speaker that combines vibration and cold to block pain, particularly during needle procedures. It is a practical application of the principles discussed in the video, demonstrating how understanding pain mechanisms can lead to innovative solutions for pain management.

💡Pain-Free

The term 'pain-free' is used in the script to describe a state where an individual does not experience any pain. The speaker criticizes the 'pain-free' goal as unrealistic and potentially harmful, as it sets an unattainable standard for patients and can lead to over-reliance on opioids.

💡Venn Diagram

A Venn diagram is a visual representation used to show the relationships between sets of things. In the context of the video, the speaker uses a Venn diagram to illustrate the overlapping elements of pain, which include physiology, fear, and control, to explain how these factors interact to influence the pain experience.

💡Distraction

Distraction is a psychological technique used to divert attention away from a stimulus, such as pain. The speaker explains how distraction works as a pain management tool, using the example of counting monkeys on a poster to activate the decision-making part of the brain and reduce the perception of pain.

💡Functional MRI

Functional MRI, or fMRI, is a neuroimaging procedure that measures and maps the brain's activity by detecting changes associated with blood flow. The speaker mentions fMRI to describe how researchers can visualize the complex neural connections involved in the pain experience.

💡Connectomes

Connectomes refer to the complete map of neural connections within the brain. The script discusses how individual connectomes can influence pain perception, with certain brain connections predisposing individuals to feel more pain than others.

💡Plasticity

Plasticity in the context of the nervous system refers to its ability to change and adapt over time. The speaker explains how the brain's plasticity can lead to the strengthening of pain-related neural connections, which can result in chronic pain even after the initial injury has healed.

💡Control

Control, in the context of the video, refers to an individual's ability to influence or manage their pain. The speaker argues that having control over pain management options, such as choosing between heat, cold, vibration, and other techniques, can significantly decrease pain and improve the patient's experience.

Highlights

Physicians have a more sophisticated understanding of pain as an alarm system that involves the nerves and the brain.

Medical professionals receive minimal education on pain, often influenced by pharmaceutical marketing.

The concept of 'pain-free' as a goal has been detrimental and is a result of marketing strategies.

Pain is presented as an essential learning system for survival, not merely a sensation to be eliminated.

The story of Christopher Wolf illustrates the dangers of opioid overprescription and the consequences of the 'no-pain' era.

Pain is better understood as a Venn diagram of physiology, fear, and control, offering different avenues for management.

The invention of Buzzy, a device combining vibration and cold, has successfully reduced pain during needle procedures.

Vibration decreases pain by triggering nerves that compete with pain signals, a concept known as gate control.

The use of cold in pain management works by signaling the brain to decrease sensations from the affected area.

Distraction techniques, such as counting, can significantly reduce the perception of pain by engaging the decision-making process.

Functional MRI studies reveal that pain is a complex network of connections involving sensation, decision-making, and emotional responses.

Expectations and past experiences greatly influence the perception of pain, highlighting the role of psychology in pain management.

The concept of 'more comfortable' is suggested as a more realistic and healthier goal than 'pain-free'.

Opioids do not turn off a pain switch but activate the reward system, which can lead to dependence and substance-use disorders.

Recovery after surgery can be effectively managed with coaching and physiologic options, reducing the need for opioids.

The speaker advocates for a healthcare system that provides options and coaching for pain management, moving away from excessive opioid prescriptions.

Pain scales have evolved from trying to objectively measure pain to assessing the impact and interference of pain on individuals.

The development of DuoTherm explores the interaction of different frequencies to cancel out pain, targeting specific nerves and areas.

The potential of combining various physiologic options, such as heat, cold, pressure, and distraction, offers a personalized approach to pain management.

Transcripts

So if you whack your thumb with a hammer, you think pain is in your thumb.

Physicians have a more sophisticated understanding.

We know that it's an alarm that goes, on nerves, to your spine,

where it is translated to your brain, and pain actually happens ...

somewhere.

It's a little vague.

We actually only get two days of pain education

throughout all of medical school, so ...

In fact, the only pain lecture I remember from the '90s

was in a dark room like this,

after being awake for 30 hours and hungry,

and finding out our noon lecture was sponsored by OxyContin.

We got pens, we got great lasagna,

and they had very cool slides that showed pain stopped by opioids.

And we learned that home opioids aren't addictive,

and if you stay ahead of pain --

(Laughter)

you can keep your patients pain-free.

And beyond the obviously egregious marketing,

I think it was framing "pain-free" as the goal

that has destroyed countless lives.

My friend's son Christopher started having severe abdominal pain

during this "no-pain" era.

Eventually, he was diagnosed with a colon disease

and had surgery his senior year.

They sent Christopher home with 90 OxyContin,

and then 90 more,

and then, as the pain started getting faster and faster ...

Uncontrolled pain is terrifying.

So when his ran out and his friends' medicine cabinets ran out,

Christopher tried heroin.

And Christopher Wolf lost his battle with substance use at age 32.

So did we misunderstand pain?

What if pain isn’t an alarm to silence

but a learning system for survival?

TED pose.

(Laughter)

(Cheers and applause)

Pain is every organism's primary learning system for survival.

I mean, it's like, "Ouch. Don't touch that."

Or, to paraphrase "The Princess Bride,"

"Life is pain, Highness."

"Pain-free" was marketing,

and it made physicians think that one pill could solve pain.

It still makes people feel like you can't be happy

if you have some pain,

and we now know

that if you want to move past pain, it takes work.

Setting the bar at "pain-free" was too high.

Plenty of people could have been more comfortable,

but they gave up because pain-free was out of reach.

We have really good new information that I'm going to share,

and so from now on, I want you to think about pain

as a Venn diagram,

with physiology, fear and control.

I'm going to tell you how each of these can give you power over pain.

Right now, I'm translating these, in my research,

into a low-back pain device to reduce opioid use.

But 20 years ago,

I just wanted to have a fast cure for needle pain,

for IV access and my kids' shots.

I was driving home one night after a graveyard shift,

and my hands were vibrating on the steering wheel,

because we needed to get the tires balanced.

I was ignoring that to think about pain,

and when I got home and reached for the door in my house,

my hand was numb.

Vibration.

So I burst in, my Boy Scout husband grabbed some frozen peas,

and we had ourselves a genuine eureka moment,

where cold and vibration blocked pain.

Over the next decade, I found the right frequency to block pain,

I got a grant, and I created Buzzy, which is vibration plus ice ...

in a bee shape.

And you put it on your arm when you’re getting an injection.

And to date, 45 million needle procedures had decreased pain,

and over 80 randomized controlled trials, independently, all around the world,

have been published.

But ...

(Cheers and applause)

At about 30 randomized controlled trials in,

one of my colleagues came to me

and confided that he was in opioid recovery.

And he asked whether or not Buzzy could let him get through

a total knee replacement drug-free.

I'd never thought about it.

It's the same pain nerve for knees as for needles,

so I said maybe.

And he did it.

Vibration plus cold replaced OxyContin.

(Applause)

So at that point, I went all in, to figure out why.

And here is what we know.

So the reason that vibration decreases pain

is because the physiology of the nerves

of light touch, pressure, stretching and motion

all races pain to the spine.

Now people have tried electricity to trigger the light-touch nerves,

but we now know that motion, shown in green,

is what's most effective at shutting the gate on sharp pain.

This is called gate control,

and the exact right frequency of vibration triggers the nerves that decrease pain.

The physiology of ice is different.

So the cold goes up to the brain, where the conductor goes,

"Obnoxious, but not dangerous.

I will decrease sensations coming from everywhere."

And it decreases pain everywhere.

If a child was so freaked out from previous experiences

that even the swab hurt ...

physiology wasn't as helpful.

So we added distraction, like a monkey poster.

And what we discovered

was combining counting plus making a decision

cut pain in half.

So, for example, "How many monkeys are actually touching the bed?"

activates the decision switchboard.

I know what you guys are doing. It's five.

(Laughter)

Here is your pain hack for the day, though.

If you do not have monkeys on hand, then find any sentence

and count how many of the letters have holes in them.

Counting, deciding. So, like, you've got a g-hole,

o-hole, a ... hole.

(Laughter)

(Laughter and applause)

I guarantee you and your family will use this.

(Laughter)

The biggest hack, though, is understanding why distraction works.

And now, through functional MRI, we can actually see pain happen.

And it's not one place.

Pain is a symphony of connections,

from the sensation area to the conductor,

to the decision switchboard,

and then to fear, memory, meaning, control.

So if the decision switchboard is occupied sorting monkeys,

it can't notify fear and meaning,

and you feel less pain.

What you feel

is mostly what you expect to feel.

Stay with me.

If you're a kid,

the same punch hurts more from a bully than from your buddy.

And if you're an adult and you feel something,

the second you think it's cancer, it hurts more and more,

until you find out it's not.

And those same kids who had horrible shot experiences

can tolerate all kinds of needle pain ...

to look cool.

(Laughter)

Because it is a different context.

These patterns, called connectomes,

are very personal,

because experiences lay down more of the same sensation.

And we now know that people who have certain areas in the brain connected

feel more pain than people with different areas connected.

And more importantly,

untreated pain or intense pain can lay down heavier connections,

so that even when your body is healed, you will still feel more pain.

It's this very plasticity and personalization

which makes the physiology, fear, control matrix so useful.

Because choosing physiologic options

that you can layer, that work for you,

decreases pain,

like heat, cold, vibration, deep relaxation, acupuncture,

capsaicin, exercise, meditation ...

There's more.

Christopher probably had 10 of these around his house

and just didn't know it.

Having control over your options decreases pain.

Deep breathing increases control.

Choosing what to focus on increases control.

Fear and control are the volume knobs for pain.

Fear controls so many of our sensations, this shouldn't be unusual,

but we don't practice it for pain.

So if you're home alone and you hear a clunk ...

your hearing becomes hypersensitive.

But when you remember your kid's home from college,

your fear dials down and your brain overrides it and says,

"Don't worry about it."

Saint Augustine called pain the greatest of evil.

But if it is a survival system, it cannot be all evil.

So instead,

think of pain as your nagging, safety-obsessed, exaggerating friend

who’s sometimes wrong.

And it’s OK to ignore or override your friend

if you know that you're safe.

This takes practice.

On a flight that was turbulent,

I had an entire cup of scalding-hot coffee dumped straight on my ankle.

Electric jolt through my scalp.

I ripped off my sock; it was already red.

It was going to blister.

There was no way I could get my foot into that little sink

to get cold water on it.

And then I remembered.

Physiology hack.

I had an unopened cold beer.

(Laughter)

Medical-grade cold beer went on my ankle, stat.

(Laughter and applause)

I had a vibrator in my carry-on, because I would.

On my ankle. And then --

(Laughter and applause)

The pain kind.

(Laughter)

And then my fear hack.

I'm like, "There's a barf bag that has holy letters,

but I'm going to put it in the pocket pouch and save it,

because then, I have increased control."

And, pain , I was no longer that concerned.

(Cheers and applause)

Although then, I realized I'm that guy,

with my bare foot sticking out in the aisle on a plane,

with a beer on it.

(Laughter)

Power over pain isn’t always pretty, but it is possible

and it is absolutely critical.

Because there’s one more misconception we have not talked about.

I honestly thought that opioids turned off some pain switch.

They turn on our reward system.

So some people feel amazing,

but most people just still feel pain, but don't care.

Now, this is a godsend for people with chronic pain diseases.

We should not take them away.

And in the trauma bay,

the more morphine in the first 24 hours after a burn or a wound,

the less post-traumatic stress,

the less chronic pain later.

But studies show that recovery after surgery

is just as well accomplished with coaching and physiologic options.

And if you're one of the people who feel amazing with opioids,

it's too risky.

A study in 2019 found

that one in 15 young adults who got opioids for their wisdom tooth removal

had substance-use disorder within a year.

Ibuprofen works better.

So what do we do?

Well, in my dream world, we have health-care systems --

paid-for options and coaching --

for Christophers everywhere.

And we quit giving double-digit prescriptions for opioids

for home recovery.

In the real world,

80,000 people died in the US last year from opioid overdoses,

and 80 percent of substance-use disorders start with a pill prescribed for pain ...

Usually taken from your friend's medicine cabinet.

People can’t afford options.

Doctors, 20 years later, still don't know them.

But you do.

You all now know to throw away the opioids in your medicine cabinet.

You now know that there are options you can use to decrease pain,

and you know that "pain-free" should be ditched

for "more comfortable."

And whether you dump scalding coffee

or pain wakes you and exhausts you every day ...

Options that are in your control ...

can allow you to reframe pain.

Thank you.

(Cheers and applause)

Whitney Pennington Rodgers: Amy, thank you, it's amazing.

So how do you think that pain scales have set us back

from this work that you're doing,

and how is the NIH treating pain and addiction differently now?

Amy Baxter: So in one of the 120 versions of this talk,

I talked about how the thing is, in the '90s,

if we wanted to “disease-ify” pain,

it meant we had to be able to measure it.

So that was where the FACES scales come from,

and they're actually very useful in the emergency department

to tell whether or not a medicine is working.

In fact, we were one of the first ones that showed, with sickle cell,

that the patient's report, based on those scales,

was what was most indicative of whether they needed to be admitted,

rather than any biologic marker.

But what we're doing now

is we're using something called the PROMIS scales,

so it’s how intense pain is on five-point scales,

how much it interferes,

so there's pain interference, pain intensity.

And the way we're looking at pain is much more on the impact for the person,

rather than trying to pretend

there's any kind of objective pain measurement.

WPR: OK.

And you mentioned that you're working on some new applications for Buzzy,

specifically for back pain.

What are some of the possibilities that we have here

for what this could do for us in the future?

AB: On my tombstone, there's going to be a vibrating bee.

It's actually called DuoTherm, not Buzzy.

But what we've learned is that there are harmonics of interaction

between the specific frequencies that cancel out the pain.

So there’s one particular nerve called the Pacinian

that has a very specific frequency range,

and by causing them to interact,

we're starting to explore more about the pain

that's coming from the fascia between the skin and between the muscles,

but that area is where we're unexplored,

and so by interacting with different frequencies

and then layering heat or cold, pressure options,

giving people the choice of so many different ways to do it,

it's really engaging all the different areas of the brain

from which pain comes.

WPR: Wow, OK. Well, thank you so much, Amy.

AB: Welcome.

Thank you, all.